Application for Employment/Volunteer

This Agency is an Equal Opportunity Employer. No question of this application is asked for the purpose of limiting or excluding any applicant’s consideration for employment because of his/her race, color, creed, religion, sex, age, national origin, military status, ancestry, disability, or sexual orientation.

Background and drug screenings will be completed on all applicants offered employment.

This position may require transporting individuals in a personal vehicle (mileage paid). Do you have a vehicle to use while on shift?

YesNo

Please indicate source of referral

Education

Name

Location

No. of Years Attended

Did You Graduate

Subjects Studied

Additional Certifications or Qualifications

Former Employers

Name of Employer

Address

City

State

Zipcode

Starting Date

--

Leaving Date

--

Job Title

Starting Salary

Ending Salary

Name of Supervisor

Supervisor's Title

Employer's Phone Number

May we contact this employer?

Description of work

Reason for leaving

Name of Employer

Address

City

State

Zipcode

Starting Date

--

Leaving Date

--

Job Title

Starting Salary

Ending Salary

Name of Supervisor

Supervisor's Title

Employer's Phone Number

May we contact this employer?

Description of work

Reason for leaving

Name of Employer

Address

City

State

Zipcode

Starting Date

--

Leaving Date

--

Job Title

Starting Salary

Ending Salary

Name of Supervisor

Supervisor's Title

Employer's Phone Number

May we contact this employer?

Description of work

Reason for leaving

Name of Employer

Address

City

State

Zipcode

Starting Date

--

Leaving Date

--

Job Title

Starting Salary

Ending Salary

Name of Supervisor

Supervisor's Title

Employer's Phone Number

May we contact this employer?

Description of work

Reason for leaving

References

Name

Address

Business

Years Known

Phone

Have you had any moving violations in the past 3 years?

YesNo

Other than traffic violations, have you ever been convicted of a crime?

YesNo

Have you been convicted of a felony within the last 5 years?

YesNo

Has child/elder abuse/neglect been investigated and/or substantiated?

YesNo

If you have answered Yes to any of the previous questions, please explain the circumstances. (This will not necessarily exclude you from consideration for a position.)

AUTHORIZATION

As an applicant for employment or volunteer at the Developmental Center of the Ozarks, I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. I grant the Agency permission to verify answers. I understand that any false statement in the application may be considered sufficient cause for rejection of the application, or for dismissal if such false statement is discovered subsequent to my employment. I hereby authorize the Developmental Center of the Ozarks to conduct an investigative consumer report on me, as defined in PL 91.508, and I understand that if any inquiry is made, more information as to its nature and scope will be supplied upon written request. If this application is considered favorably, I agree to abide by and comply with all of the Policies, Procedures, and Guidelines of the Developmental Center of the Ozarks and the Program for which I am hired. I also understand that the offer of employment is not final until it is in writing and signed by an authorized DCO representative.